Friday, March 2, 2012

This is another one of those window-to-the-future articles, where an enterprising department has taken a commonplace disease with a relatively high admission rate and tried to change the status quo.

As they note, bronchiolitis is the #1 cause of admission for children < 1 year, it accounts for 150,000 admissions annually, and costs $500 million. One of the key clinical features that keeps otherwise well-appearing children in the hospital is hypoxia, specifically < 90% saturation by pulse oximetry as recommended by the American Academy of Pediatrics.

This is a retrospective chart review that essentially says "we did this and we like it." 4,194 relevant charts were reviewed, 57% of which were discharged without home oxygen, 15% were discharged on oxygen, and 28% were admitted. Of the discharged patients, 4% of the no-home-oxygen patients returned for eventual admission compared with 6% of the discharge-on-oxygen patients. Overall, this led to a 25% relative decrease in admissions for bronchiolitis at their institution, compared to historical controls.

More confirmatory study is needed - it's a little different at mile-high Denver than the rest of the U.S. - but this may be a promising way to reduce admissions for bronchiolitis. It is also suggestive of what is likely the new future of cost-containment medicine, at least where the malpractice environment will tolerate it - an increasing proportion of higher-risk discharges with, in theory, closer follow-up that saves money in the long run.

Wednesday, February 29, 2012

...but don't use either of them first-line. And, of course, your mileage may vary based on local resistance patterns.

This study, in JAMA, is from Seattle, where their ciprofloxacin resistance in e. coli is extraordinarily low - only 4%. Their e. coli resistance to cefpodoxime, a third-generation cephalosporin, was 8%. They randomized 300 women with uncomplicated cystitis into, luckily, two rather similar groups - and found a 93% clinical cure rate for ciprofloxacin and an 82% cure rate with cefpodoxime. Microbiologic cure rate at 5 days was 96% in the ciprofloxacin group and 81% in the cefpodoxime group. And, then, there are a bunch of minor details in laborious text regarding the microbiology of the non-responders, but I'm not sure any of it's actually relevant. Seven women in the ciprofloxacin group required treatment for an "adverse effect" (nausea, headache, vaginal discomfort), compared with three in the cefpodoxime group.

However, neither of these agents should be considered first-line for uncomplicated cystitis. Nitrofurantoin and fosfomycin are recommended as first-line therapy in the most recent guidelines, along with trimethoprim-sulfamethoxazole depending on local resistance. After that, consult your local antibiogram to determine whether beta-lactams are viable, or whether a fluroquinolone or a third-generation cephalosporin should be your next option.

Monday, February 27, 2012

Apparently, rather than spend a lot of money on the back-end with patient satisfaction initiatives, all you really need is soothing artwork in your ED waiting room.

This is a rather simple, prospective cohort study in which research associates observed the waiting room behaviors of waiting patients. They observed several different behaviors, but mostly were interested in "disruptive" behaviors - fidgeting, aggressive behavior, pacing, getting out of seat, etc. After initial observation, artwork of "natural beauty" along with a DVD of soothing nature scenes was introduced into the waiting room of the two EDs in the study.

And, essentially, the ED waiting experience appeared more pleasant, according to their surrogate measures of patient disruptive behaviors - significant improvements in reducing out of seat behavior, fidgeting, front desk inquiries.

So, art? Probably good, although this is a relatively methodologically weak study.